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Desmineralização e remineralização do esmalte dentário : compreensão dos mecanismos bioquímicos e otimização das estratégias preventivas através da comunicação
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O esmalte dentário está constantemente sujeito a um equilíbrio dinâmico entre desmineralização e remineralização. A desmineralização ocorre quando o ambiente oral provoca uma queda do pH abaixo do limiar crítico, o que leva à dissolução dos cristais de hidroxiapatita. Se o processo continuar sem reparação, resulta na formação de lesões cariosas. No entento nem toda a lesão cariosa inicial é irreversível. As lesões não cavitadas podem ser remineralizadas ou estabilizadas. A irreversibilidade está associada à cavitação.
A remineralização baseia-se no retorno dos íons cálcio e fosfato provenientes da saliva, com a eventual participação dos fluoretos para estabilizar a forma mineral (fluoroapatita), menos solúvel.
No entanto, este processo não é simples : existem várias fases intermediárias antes de se atingir uma estrutura semelhante à apatita biológica.
Diversas estratégias de prevenção e promoção da remineralização foram estudadas: o uso de flúor (tópico, dentífricos, vernizes) como agente amplamente reconhecido por favorecer a remineralização e inibir a desmineralização, inclusive reduzindo o limiar crítico; abordagens biomiméticas, como a nano-hidroxiapatita, peptídeos (por exemplo, amelogenina, leucine-rich amelogenin peptide), proteínas dentinárias ou extratos naturais, polifosfatos e vidros bioativos. Técnicas combinadas (flúor + cálcio/fosfato ou flúor + biomiméticos) apresentam melhores resultados na remineralização de lesões iniciais (manchas brancas, erosões superficiais) do que as estratégias simples.
Um aspecto menos estudado, mas crucial, é a comunicação — ou seja, como informar e persuadir os pacientes a adotar comportamentos favoráveis: higiene oral, alimentação adequada, uso regular de flúor, etc. A eficácia das estratégias também depende da compreensão, da adesão, da motivação e das barreiras culturais e sociais. Embora os artigos tratem pouco deste ângulo, alguns enfatizam a importância de campanhas, da educação, do aconselhamento individualizado e do papel do profissional.
Dental enamel is constantly subject to a dynamic balance between demineralization and remineralization. Demineralization occurs when the oral environment causes the pH to fall below the critical threshold, leading to the dissolution of hydroxyapatite crystals. If this process continues without repair, it results in the formation of carious lesions. However, not every initial carious lesion is irreversible. Non-cavitated lesions can be remineralized or stabilized. Irreversibility is associated with cavitation. Remineralization is based on the return of calcium and phosphate ions from saliva, with the possible involvement of fluoride to stabilize the mineral form as fluorapatite, which is less soluble.However, this process is not simple: several intermediate phases occur before a structure similar to biological apatite is achieved. Various strategies for preventing demineralization and promoting remineralization have been studied. These include the use of fluoride, such as topical fluoride, toothpastes, and varnishes, which is widely recognized for promoting remineralization and inhibiting demineralization, including by lowering the critical pH threshold. Biomimetic approaches have also been investigated, including nano-hydroxyapatite, peptides such as amelogenin and leucine-rich amelogenin peptide, dentin-derived proteins, natural extracts, polyphosphates, and bioactive glasses. Combined techniques, such as fluoride with calcium and phosphate or fluoride with biomimetic agents, provide better results in the remineralization of initial lesions, including white spot lesions and superficial erosions, than single strategies. A less studied but crucial aspect is communication, namely how to inform and persuade patients to adopt beneficial behaviours, such as maintaining good oral hygiene, following an appropriate diet, and regularly using fluoride. The effectiveness of these strategies also depends on patients’ understanding, adherence, motivation, and cultural and social barriers. Although scientific articles rarely address this aspect, some emphasize the importance of public health campaigns, education, individualized counselling, and the role of dental professionals.
L’émail dentaire est constamment soumis à un équilibre dynamique entre déminéralisation et reminéralisation. La déminéralisation se produit lorsque l’environnement buccal entraîne une diminution du pH en dessous du seuil critique, ce qui provoque la dissolution des cristaux d’hydroxyapatite. Si ce processus se poursuit sans réparation, il conduit à la formation de lésions carieuses. Cependant, toute lésion carieuse initiale n’est pas irréversible. Les lésions non cavitaires peuvent être reminéralisées ou stabilisées. L’irréversibilité est associée à la cavitation. La reminéralisation repose sur le retour des ions calcium et phosphate provenant de la salive, avec la participation éventuelle du fluor pour stabiliser la phase minérale sous forme de fluorapatite, moins soluble. Cependant, ce processus n’est pas simple : plusieurs étapes intermédiaires sont nécessaires avant d’aboutir à une structure comparable à l’apatite biologique. Diverses stratégies de prévention et de promotion de la reminéralisation ont été étudiées : l’utilisation du fluor (applications topiques, dentifrices, vernis), largement reconnu pour favoriser la reminéralisation et inhiber la déminéralisation, notamment en abaissant le seuil critique ; des approches biomimétiques telles que la nano-hydroxyapatite, les peptides (par exemple l’amélogénine ou le peptide riche en leucine dérivé de l’amélogénine), les protéines dentinaires ou les extraits naturels, les polyphosphates ainsi que les verres bioactifs. Les approches combinées (fluor + calcium/phosphate ou fluor + agents biomimétiques) montrent de meilleurs résultats pour la reminéralisation des lésions initiales (taches blanches, érosions superficielles) que les stratégies utilisées isolément. Un aspect moins étudié, mais essentiel, est la communication, c’est-à-dire la manière d’informer et de convaincre les patients d’adopter des comportements favorables à la santé bucco-dentaire : hygiène orale, alimentation adaptée, utilisation régulière du fluor, etc. L’efficacité des stratégies dépend également de la compréhension, de l’adhésion, de la motivation ainsi que des barrières culturelles et sociales. Bien que les publications abordent encore peu cet aspect, certaines soulignent l’importance des campagnes de sensibilisation, de l’éducation à la santé, du conseil individualisé et du rôle du professionnel de santé.
Dental enamel is constantly subject to a dynamic balance between demineralization and remineralization. Demineralization occurs when the oral environment causes the pH to fall below the critical threshold, leading to the dissolution of hydroxyapatite crystals. If this process continues without repair, it results in the formation of carious lesions. However, not every initial carious lesion is irreversible. Non-cavitated lesions can be remineralized or stabilized. Irreversibility is associated with cavitation. Remineralization is based on the return of calcium and phosphate ions from saliva, with the possible involvement of fluoride to stabilize the mineral form as fluorapatite, which is less soluble.However, this process is not simple: several intermediate phases occur before a structure similar to biological apatite is achieved. Various strategies for preventing demineralization and promoting remineralization have been studied. These include the use of fluoride, such as topical fluoride, toothpastes, and varnishes, which is widely recognized for promoting remineralization and inhibiting demineralization, including by lowering the critical pH threshold. Biomimetic approaches have also been investigated, including nano-hydroxyapatite, peptides such as amelogenin and leucine-rich amelogenin peptide, dentin-derived proteins, natural extracts, polyphosphates, and bioactive glasses. Combined techniques, such as fluoride with calcium and phosphate or fluoride with biomimetic agents, provide better results in the remineralization of initial lesions, including white spot lesions and superficial erosions, than single strategies. A less studied but crucial aspect is communication, namely how to inform and persuade patients to adopt beneficial behaviours, such as maintaining good oral hygiene, following an appropriate diet, and regularly using fluoride. The effectiveness of these strategies also depends on patients’ understanding, adherence, motivation, and cultural and social barriers. Although scientific articles rarely address this aspect, some emphasize the importance of public health campaigns, education, individualized counselling, and the role of dental professionals.
L’émail dentaire est constamment soumis à un équilibre dynamique entre déminéralisation et reminéralisation. La déminéralisation se produit lorsque l’environnement buccal entraîne une diminution du pH en dessous du seuil critique, ce qui provoque la dissolution des cristaux d’hydroxyapatite. Si ce processus se poursuit sans réparation, il conduit à la formation de lésions carieuses. Cependant, toute lésion carieuse initiale n’est pas irréversible. Les lésions non cavitaires peuvent être reminéralisées ou stabilisées. L’irréversibilité est associée à la cavitation. La reminéralisation repose sur le retour des ions calcium et phosphate provenant de la salive, avec la participation éventuelle du fluor pour stabiliser la phase minérale sous forme de fluorapatite, moins soluble. Cependant, ce processus n’est pas simple : plusieurs étapes intermédiaires sont nécessaires avant d’aboutir à une structure comparable à l’apatite biologique. Diverses stratégies de prévention et de promotion de la reminéralisation ont été étudiées : l’utilisation du fluor (applications topiques, dentifrices, vernis), largement reconnu pour favoriser la reminéralisation et inhiber la déminéralisation, notamment en abaissant le seuil critique ; des approches biomimétiques telles que la nano-hydroxyapatite, les peptides (par exemple l’amélogénine ou le peptide riche en leucine dérivé de l’amélogénine), les protéines dentinaires ou les extraits naturels, les polyphosphates ainsi que les verres bioactifs. Les approches combinées (fluor + calcium/phosphate ou fluor + agents biomimétiques) montrent de meilleurs résultats pour la reminéralisation des lésions initiales (taches blanches, érosions superficielles) que les stratégies utilisées isolément. Un aspect moins étudié, mais essentiel, est la communication, c’est-à-dire la manière d’informer et de convaincre les patients d’adopter des comportements favorables à la santé bucco-dentaire : hygiène orale, alimentation adaptée, utilisation régulière du fluor, etc. L’efficacité des stratégies dépend également de la compréhension, de l’adhésion, de la motivation ainsi que des barrières culturelles et sociales. Bien que les publications abordent encore peu cet aspect, certaines soulignent l’importance des campagnes de sensibilisation, de l’éducation à la santé, du conseil individualisé et du rôle du professionnel de santé.
Descrição
Dissertação para obtenção do grau de Mestre no Instituto Universitário Egas Moniz
Palavras-chave
Esmalte Desmineralização Remineralização Prevenção